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Spirituality - Another Vital Sign on the Doctor's Checklist?

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The machine, beeping steadily away in the background, reassuringly spells life.

Suddenly it goes haywire. Something's wrong. The patient needs urgent attention. Visiting family members panic as the monitor warns of their loved one's impending doom.

In rush the concerned clinicians - first the nurses, then the doctors. It's action stations.

Finally, depending on whether the writers have scripted happy or sad endings, the music is jubilant or sorrowful.

And then the credits roll.

We are all familiar with Hollywood's archetypal hospital scenes depicting the fragility that seems to separate life from death. And we might hope and pray never to star in such a drama in real life.

But tracking and reacting to dramatic changes in a patient's vital signs are an essential part of modern-day healthcare.

So are we recognising and responding to all the vital signs?

Dr Christina Puchalski, of the George Washington Institute for Spirituality and Health at George Washington University, thinks not. As an untiring champion of the need to assess, acknowledge and accommodate the spiritual needs of patients in hospital settings, this Professor of Medicine has "pioneered novel clinical and educational techniques for integrating spirituality into numerous disciplines in healthcare". And following two decades of research and advocacy she has just published a comprehensive textbook on the subject.

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Professor Puchalski by Hamid Benalia, copyright Cicely Saunders Institute

Dr Puchalski recently visited King's College London to deliver the Sir Halley Stewart Trust International Lecture at the Cicely Saunders Institute.

Among the paradigm-shifting aspirations she voiced was the hope that clinicians will one day routinely recognise spirituality as a vital sign.

However, many efforts to promote the importance of spirituality as part of a more "whole-health" approach to healthcare have floundered on the reefs of definition. This was one of the points taken up at a 2009 Consensus Conference on improving the spiritual element of palliative care. The clinicians and non-clinicians at the conference - some religious, others not - came to the following workable definition:

Spirituality is the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature and to the significant or sacred.

She noted that 'significant' and 'sacred' can mean very different things to people. But whether worship of God, love of nature and beauty or anything else that holds ultimate meaning for a person, Dr Puchalski has consistently found this "aspect of humanity" to be key to the wellbeing of individuals undergoing medical treatment.

How do you recognise the state of someone's spiritual well-being? Such a vital sign would not be tracked on a digital display or measured by any equipment. Spirituality is highly individual and so, too, are the occasions when it is out of kilter. Valuing the uniqueness of the patient is crucial.

This was illustrated by Dr Puchalski during her lecture, when she movingly spoke of her mother's treatment for dementia and how two doctors involved in her care represented opposite ends of the spectrum of desirable practice.

The first doctor breezed in with a template of questions designed to test a patient's mental competence. There was no eye contact as he went through the list and no effort to notice the individuality of the person he was supposed to be caring for. Appalled, Dr Puchalski checked off to the offending physician some of the things he had missed, such as appreciating her mother's character and the rich life she had lived. He hadn't asked her about her family and what she loves. Nor had he showed any interest in understanding what was important to her, including her lifelong Roman Catholic faith.

The second doctor, however - attending just a couple of weeks before her mother's passing - saw beyond the medical condition to the uniqueness of the individual in his care. He achieved such a rapport with his patient that they actually shared a banana. More astoundingly, when the doctor left them, her mother - who had barely communicated to anyone for months - turned to her daughter and said: "Now Christina, that is a good doctor!"

Interestingly, Dr Puchalski made it clear that addressing a disturbed spirituality does not simply calm a troubled mind but can also bring relief to the body. She described the case of a man whose increasingly acute pain was not alleviated by the medication he took. Then it was recognised he was suffering a sense of alienation connected with his church. As soon as this was successfully attended to, his pain quieted.

Closing her London talk the pioneering clinician stressed her experience was of the United States healthcare system, and emphasised the UK would continue to fine tune its own model for increasingly including spirituality in healthcare.

Many points in her lecture, though, were universal - including the fact that as we are sensitive to the spiritual needs of others the blessings are mutual. She said:

We are changed and healed by our patients as much as the other way round.

I can't help but feel the second doctor's obvious love of his patient and his recognition of her as an individual reached through the symptoms that had befogged Dr Puchalski's mother to reveal a consciousness still intact.

Could this point to the deeper potential for spiritual care in a health setting - that such love is able to throw light on a spiritual identity which can sometimes seem eclipsed but is never truly absent?

If so, then spirituality is not only a vital sign to look for but an essential resource to help lift the thought of both patient and carer above the physical and emotional demands of dealing with a medical diagnosis to the healing recognition of a spiritual selfhood that remains intact.

So, let's imagine we're back on the film set.

"Lights. Camera. Action!"

Scene 1: A hospital room.

The patient is lying in his hospital bed. His life-signs monitor is beeping away in the background.

The nurse dressing his wounds is chatting with him. He proudly talks about how well his thirty-year old son has turned out. The nurse asks: "And do you have any other children?"

Silence. Then tears. She asks: "What's the problem?" But he won't answer. Although the life-signs monitor hardly registers a change she can feel the depth of the patient's unspoken inner turmoil. She holds his arm and takes time to share the silence till his weeping ends. He says "Sorry!" and forces a smile. She smiles back.

Scene 2: A boardroom.

The Interdisciplinary Team are gathered together. The nurse tells the doctor, mental health counsellor and chaplain how her conversation shed light on the patient's inner struggle. They agree they all need to respond to the patient's deeper distress as well as the physical pain. The doctor says that when he'd sat with him and inquired about his spiritual beliefs or practices the patient had hesitated before saying he was a Christian. The chaplain says she will pay a call.

Scene 3: The hospital room.

The chaplain's compassion is clearly touching the patient as they, too, talk about how dear his son is to him and as he fondly reminisces about his wife, who he lost to illness a decade ago. He doesn't mention another child.

They also exchange stories of their mutual love of nature.

Gently probing, the chaplain asks "Is there anything on your mind to attend to before you die?" But he just answers with a smile: "My rose-beds!" She laughs along with him.

Building on the rapport they have achieved, she quietly asks: "Is there anything you wish had turned out differently?"

The chaplain sits by the patient's bedside quietly, waiting, as the question hangs in the air.

Silence. Tears again. But when the sobbing stops the patient turns to the chaplain and the story pours out. His daughter decided to live with her boyfriend without marrying and he rejected the pair as "living in sin". They haven't spoken for many years. The patient says he is angry with God for giving him a daughter who wouldn't live up to the moral standards he believes in.

The chaplain pauses, praying thoughtfully to herself. Then she clasps the patient's hand, and says:

"Do you think it might be possible that God loves you and your daughter and her boyfriend - and that He wants you to fully embrace them in your heart?"

Scene 4: The hospital room.

The patient is again pictured with tears streaming down his face. But this time he is clutching a telephone. The scene cuts to a woman on her phone who is also crying as she squeezes her partner's hand.

Scene 5: The hospital lobby.

The patient hugs the nurse and then the chaplain as he leaves the hospital and walks into a crisp autumn morning. Looking totally at peace he walks down the road, sees a local church, hesitates and then enters.

He sits alone on a pew staring blankly into space for a few moments. Then he breaks into a broad, joyful smile.

The soundtrack is Beethoven's Ode to Joy as the picture fades out and the credits roll.

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